Penile Rehabilitation after Radical Prostatectomy

Transcription

1 Penile Rehabilitation after Radical Prostatectomy The PRO Position John P. Mulhall MD MSc FECSM FACS Director, Sexual & Reproductive Medicine Program Urology Service Memorial Sloan Kettering Cancer Center

2 FACTS EFR not routine after RP: 55% (14-97%) Back to baseline EFR uncommon: 22% (4% >60y) Technology has not changed these figures ED independent predictor of bother and depression Greatest barrier to rehabilitation is surgeon apathy Greatest patient barrier is cost of medication

3 Dr. Trost will say. Its costly! There are side effects There is no level 1 EBM The animal model is not representative of humans

4 ED Pathophysiology Smooth Muscle Damage

5 CCSM Alterations After RP Pre-op 2 Months After RP Iacono F et al. J Urol, 163: , 2005

6 % Patients 100% 90% 80% 70% 60% 50% 40% 30% 20% 10% 0% CAI CVOD < 4 < 8 < 12 > 12 Time interval since radical prostatectomy (Months)

7 Penile Rehabilitation Definition: Penile rehabilitation is defined as the use of any drug or device to maximize erectile function recovery Purpose: The prevention of smooth muscle and endothelial structural alterations to maximize chances of a man returning to his preoperative erectile function level Candidates: - Radical pelvic surgery - Pelvic radiation - Diabetes - Pelvic fracture

8 Penile Rehabilitation Survey ISSM Members

9 ICSM 2009 Recommendation Grade C Given the strong animal and basic science evidence and understanding the strengths and weaknesses of the existing human studies and the negative consequences of long-term ED after RP, the committee suggests that penile rehabilitation has significant potential benefits for the patient/partner and should be considered after RP. ICSM Mulhall JP, Brock GE et al. JSM 2010

10 Animal Data Muller A et al. The functional and structural consequences of cavernous nerve injury are ameliorated by sildenafil citrate. J Sex Med, 2008; Epub ahead of print Kovanecz I et al. Long-term continuous sildenafil treatment ameliorates CVOD induced by cavernosal nerve resection in the rats. IJIR, 2008; 20:202 Ferrini M et al. Vardenafil prevents fibrosis and loiss of smooth muscle after bilateral cavernosal nerve resection in the rat. Urology, 2006; 68:429 Vignozzi L et al. Effect of chronic tadalafil administration on penile hypoxia induced by cavernous neurotomy in the rat. J Sex Med; 2006; 3:419 Kovanecz I et al. Chronic daily tadalafil prevents the corporal fibrosis and venocclusive dysfunction that occurs after cavernosal nerve resection. BJUI; 2008; 101:203 Lysiak JJ et al. Tadalafil increases AKT and extracellular signal-related kinase 1/2 activation and prevents apoptotic cell death in the penis following denervation. J Urol, 2008; 179:779

11 RCT in Post-RP Rehabilitation Sildenafil 1 - n=76, BNS, P v S50 v S100, 1-9m - Natural erections assessed at 11m - 27% responders in V v 4% in P arm Vardenafil 2 (REINVENT) - n=483, BNS, P v L10 QD v L20 OD, 1-9m - Assessments: 9m (EOT), 11m (P), 13m (V) - L20 OD > L10 QD at 9m, no at 11 or 13m Tadalafil 3 (REACCT) - n=423, BNS, P v C5 QD v C20 OD, 1-9m - Similar assessment and outcomes to REINVENT - Penile length preservation 1. Padma-Nathan H et al. IJIR 2008; 2. Montorsi F et al. Eur Urol 2008; 3. Montorsi F et al. Eur Urol (accepted)

12 Current Rehabilitation Strategies PDE5i - Prevention of endothelial structural alterations 1,2 - Prevention of smooth muscle structural alterations 3 - Preservation of smooth muscle relaxation profile 4 - Neuroregeneration 5,6 - Erection-independent cavernosal oxygenation? 7 ICI VED - Oxygenation CCS< stretch -Stretch 1. Rosano et al. Eur Urol 2004; 2. Desouza et al. Diabetes Care, 2002; 3. Schwartz et al. J Urol 2007; 4. Wayman et al. ESSM 2006; 5. Zhang et al. Stroke 2002; 6. Zhang et al. Brain Research, 2008; 7. Ghofrani et al. JACC 2004

13 Given the potentially devastating consequences of acute onset, long-term ED after RP, should we not be discussing rehabilitation with these men while we await definitive evidence confirming or refuting its benefit and thus facilitate the patient to making the final decision

14 Principal Arguments Against Unproven strategy - Lack of level I EBM Translating animal data to human model Cost

15 Principal Arguments in Favor ED associated with depression and reduced QOL Apathy leads to time-dependent changes in CCSM Signals from studies are clear & robust Sexual medicine experts are routinely doing rehabilitation post-rp

16 Is Dr. Trost?